Exoskeleton and End-Effector Robots for Upper and Lower Limbs Rehabilitation: Narrative Review

A scoping review of the use of intelligent assistive technologies in rehabilitation practice with older adults

PURPOSE

There is growing interest in intelligent assistive technologies (IATs) in the rehabilitation and support of older adults, however, the factors contributing to or preventing their use in practice are not well understood. This study aimed to develop an overview of current knowledge on barriers and facilitators to the use of smart technologies in rehabilitative practice with older adults.

MATERIALS AND METHODS

We undertook a scoping review following guidelines proposed by Arksey and O'Malley (2005) and Levac et al. (2010). A computerised literature search was conducted using the Scopus and Ovid databases, yielding 7995 citations. Of these, 94 studies met inclusion criteria. Analysis of extracted data identified themes which were explored in semi-structured interviews with a purposefully selected sample of seven clinical rehabilitation practitioners (three physical therapists, two occupational therapists, and two speech-language pathologists).

RESULTS

Barriers and facilitators to using these technologies were associated with accessibility, reported effectiveness, usability, patient-centred considerations, and staff considerations.

CONCLUSIONS

Collaborative efforts of policy-makers, researchers, manufacturers, rehabilitation professionals, and older persons are needed to improve the design of technologies, develop appropriate funding and reimbursement strategies, and minimise barriers to their appropriate use to support independence and quality of life. Any strategies to improve upon barriers to prescribing smart technologies for older people should leverage the expertise of rehabilitation professionals operating at the interface between older people; their health/mobility; their families; and technology-based solutions.

Effects of Rehabilitation Robot Training on Physical Function, Functional Recovery, and Daily Living Activities in Patients with Sub-Acute Stroke

Stroke often results in sensory deficits, muscular weakness, and diminished postural control, thereby restricting mobility and functional capabilities. It is important to promote neuroplasticity by implementing task-oriented exercises that induce changes in patients. Therefore, this study aimed to investigate the effects of rehabilitation robot training on physical function, functional recovery, and activities of daily living (ADLs) in patients with subacute stroke. The study participants were patients with subacute stroke receiving treatment at Hospitals A and B. They were selected as research subjects based on selection and exclusion criteria. The experimental group received rehabilitation robot training in sessions of 30 min, five times weekly, for a total of 20 sessions over four weeks. Conversely, the control group underwent standard rehabilitation equipment training with an identical frequency, duration, and number of sessions. Measurements were taken before and after the training period to assess changes in physical function, functional recovery, and activities of daily living using tools such as the MMT, BBS, FBG, FAC, FIM, and MBI. The results were as follows: in the within-group comparison, the rehabilitation robot training group showed significant differences in MMT, BBS, FBG, FAC, FIM, and MBI (p < 0.05), while the control group showed significant differences in FIM (p < 0.05). Statistically significant differences were observed in the time, group, and time × group interaction effects among the MMT, static seated FBG, dynamic seated FBG, FIM, and MBI (p < 0.05). Based on these results, rehabilitation robotic training resulted in significant improvements in physical function, functional recovery, and activities of daily living in patients with subacute stroke. Based on these findings, providing a basic protocol for a rehabilitation program that applies rehabilitation robot training to patients with subacute stroke may offer more effective treatment and outcomes in the future.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

The clinical effects of brain-computer interface with robot on upper-limb function for post-stroke rehabilitation: a meta-analysis and systematic review

PURPOSE

Many recent clinical studies have suggested that the combination of brain-computer interfaces (BCIs) can induce neurological recovery and improvement in motor function. In this review, we performed a systematic review and meta-analysis to evaluate the clinical effects of BCI-robot systems.

METHODS

The articles published from January 2010 to December 2020 have been searched by using the databases (EMBASE, PubMed, CINAHL, EBSCO, Web of Science and manual search). The single-group studies were qualitatively described, and only the controlled-trial studies were included for the meta-analysis. The mean difference (MD) of Fugl-Meyer Assessment (FMA) scores were pooled and the random-effects model method was used to perform the meta-analysis. The PRISMA criteria were followed in current review.

RESULTS

A total of 897 records were identified, eight single-group studies and 11 controlled-trial studies were included in our review. The systematic analysis indicated that the BCI-robot systems had a significant improvement on motor function recovery. The meta-analysis showed there were no statistic differences between BCI-robot groups and robot groups, neither in the immediate effects nor long-term effects (p > 0.05).

CONCLUSION

The use of BCI-robot systems has significant improvement on the motor function recovery of hemiparetic upper-limb, and there is a sustaining effect. The meta-analysis showed no statistical difference between the experimental group (BCI-robot) and the control group (robot). However, there are a few shortcomings in the experimental design of existing studies, more clinical trials need to be conducted, and the experimental design needs to be more rigorous.Implications for RehabilitationIn this review, we evaluated the clinical effects of brain-computer interface with robot on upper-limb function for post-stroke rehabilitation. After we screened the databases, 19 articles were included in this review. These articles all clinical trial research, they all used non-invasive brain-computer interfaces and upper-limb robot.We conducted the systematic review with nine articles, the result indicated that the BCI-robot system had a significant improvement on motor function recovery. Eleven articles were included for the meta-analysis, the result showed there were no statistic differences between BCI-robot groups and robot groups, neither in the immediate effects nor long-term effects.We thought the result of meta-analysis which showed no statistic difference was probably caused by the heterogenicity of clinical trial designs of these articles.We thought the BCI-robot systems are promising strategies for post-stroke rehabilitation. And we gave several suggestions for further research: (1) The experimental design should be more rigorous, and describe the experimental designs in detail, especially the control group intervention, to make the experiment replicability. (2) New evaluation criteria need to be established, more objective assessment such as biomechanical assessment, fMRI should be utilised as the primary outcome. (3) More clinical studies with larger sample size, novel external devices, and BCI systems need to be conducted to investigate the differences between BCI-robot system and other interventions. (4) Further research could shift the focus to the patients who are in subacute stage, to explore if the early BCI training can make a positive impact on cerebral cortical recovery.

The effect of the Lokomat® robotic-orthosis system on lower extremity rehabilitation in patients with stroke: a systematic review and meta-analysis

Background

The Lokomat® is a device utilized for gait training in post-stroke patients. Through a systematic review, the objective was to determine whether robot-assisted gait training with the Lokomat® is more effective in enhancing lower extremity rehabilitation in patients with stroke in comparison to conventional physical therapy (CPT).

Methods

In this study, a systematic search was conducted in various databases, including CINAHL, MEDLINE, PubMed, Embase, Cochrane Library, Scopus, Web of Science, and Physiotherapy Evidence Database (PEDro), as well as bibliographies of previous meta-analyses, to identify all randomized controlled trials that investigated the use of Lokomat® devices in adult stroke patients. The study aimed to derive pooled estimates of standardized mean differences for six outcomes, namely, Fugl-Meyer Assessment lower-extremity subscale (FMA-LE), Berg Balance Scale (BBS), gait speed, functional ambulation category scale (FAC), timed up and go (TUG), and functional independence measure (FIM), through random effects meta-analyses.

Results

The review analyzed 21 studies with a total of 709 participants and found that the use of Lokomat® in stroke patients resulted in favorable outcomes for the recovery of balance as measured by the BBS (mean difference = 2.71, 95% CI 1.39 to 4.03; p < 0.0001). However, the FAC showed that Lokomat® was less effective than the CPT group (mean difference = -0.28, 95% CI -0.45 to 0.11, P = 0.001). There were no significant differences in FMA-LE (mean difference = 1.27, 95% CI -0.88 to 3.42, P = 0.25), gait speed (mean difference = 0.02, 95% CI -0.03 to 0.07, P = 0.44), TUG (mean difference = -0.12, 95% CI -0.71 to 0.46, P = 0.68), or FIM (mean difference = 2.12, 95% CI -2.92 to 7.16, P = 0.41) between the Lokomat® and CPT groups for stroke patients.

Conclusion

Our results indicate that, with the exception of more notable improvements in balance, robot-assisted gait training utilizing the Lokomat® was not superior to CPT based on the current literature. Considering its ability to reduce therapists' work intensity and burden, the way in which Lokomat® is applied should be strengthened, or future randomized controlled trial studies should use more sensitive assessment criteria.

Effect of exoskeleton manipulator on hand function rehabilitation for postburn patients

PURPOSE

Patients with scar contracture deformities caused by hand burns were treated with an exoskeleton manipulator system, which was equipped with games to explore its clinical application value.

METHODS

Twenty patients who were treated for post-burn scars of bilateral hands between October 2020 and June 2021 were selected (ChiCTR2000036232). The patients were divided into two groups: control, 10 patients (traditional outpatient treatment); and experimental, 10 patients (exoskeleton manipulator system treatment). We compared the change in the total active motion (TAM) value, grip strength, scar improvement, and postoperative pain improvement.

RESULTS

After 3 months of rehabilitation training, the improvement of thumb TAM was 33.80 ± 11.38 ° in the experimental group and 23.2 ± 6.13 ° in the control group. With respect to the index finger TAM, the improvement in the experimental and control groups was 84.50 ± 30.96 ° and 54.80 ± 15.89 °, respectively. The middle finger TAM of the experimental and control groups improved by 86.75 ± 32.85 ° and 60.25 ± 17.97 °, respectively. However, improvement of grip strength, scar score, and pain score were similar between the two groups.

CONCLUSIONS

The exoskeleton manipulator system has excellent effects in improving burned hand joint movement, which is suitable for hand burn patients and has beneficial clinical effects.Implications for rehabilitationExercise is an effective means to improve the hand function of burn patients.The application of mechanical devices in the rehabilitation of burned hands can effectively help patients exercise.The A5 Hand Function Training System is an exoskeleton mechanical device that can exercise the small joints of the hand. It assists patients in using different computer games during treatment.

Development and Testing of a Soft Exoskeleton Robotic Hand Training Device

Hand-function recovery is often a goal for stroke survivors undergoing therapy. This work aimed to design, build, and verify a pneumatic hand training device for its eventual use in post-stroke rehabilitation. The system was built considering prior research in the field of robotic hand rehabilitation as well as specifications and design constraints developed with physiotherapists. The system contained pneumatic airbag actuators for the fingers and thumb of the hand, a set of flex, pressure, and flow sensors, and software and hardware controls. An experiment with the system was carried out on 30 healthy individuals. The sensor readings were analyzed for repeatability and reliability. Position sensors and an approximate biomechanical model of the index finger were used to estimate joint angles during operation. A survey was also issued to the users to evaluate their comfort levels with the device. It was found that the system was safe and comfortable when moving the fingers of the hand into an extension.

The effectiveness of robotic-assisted upper limb rehabilitation to improve upper limb function in patients with cervical spinal cord injuries: a systematic literature review

Background

Spinal Cord Injury (SCI) damages corticospinal tracts and descending motor pathways responsible for transmitting signals from the brain to the spinal cord, leading to temporary or permanent changes in sensation, motor function, strength, and body function below the site of injury. Cervical SCI (cSCI), which leads to tetraplegia, causes severe functional upper limb (UL) impairments that increase falls risk, limits independence, and leads to difficulties with activities of daily living (ADLs). Robotic therapy (RT) has been developed in recent decades as a new treatment approach for people with cervical spinal cord injuries (cSCI). The present review aimed to explore current available evidence and studies regarding the effectiveness of RT for individuals with cSCI in improving UL function, identify current research gaps and future research directions.

Method

This review was conducted by searching PubMed, CINAHL, Medline, Embase, and APA PsycInfo for relevant studies published from January 2010 to January 2022. Selected studies were analyzed with a focus on the patients' self-perception of limited UL function and level of independence in activities of daily living. In addition, the JBI Critical Appraisal checklist was used to assess study quality.

Results

A total of 7 articles involving 87 patients (74 males and 13 females) were included in the analysis, with four studies utilizing exoskeleton and three studies utilizing end-effector robotic devices, respectively. The quality of these studies varied between JBI Critical Appraisal scores of 4 to 8. Several studies lacked blinding and a control group which affected internal validity. Nevertheless, four out of seven studies demonstrated statistically significant improvements in outcome measurements on UL function and strength after RT.

Conclusion

This review provided mixed evidence regarding the effectiveness of RT as a promising intervention approach to improve upper limb function in participants with cSCI. Although RT was shown to be safe, feasible, and reduces active therapist time, further research on the long-term effects of UL RT is still needed. Nevertheless, this review serves as a useful reference for researchers to further develop exoskeletons with practical and plausible applications toward geriatric orthopaedics.

Impact of Robotic-Assisted Gait Training in Subacute Spinal Cord Injury Patients on Outcome Measure

The improvement of walking ability is a primary goal for spinal cord injury (SCI) patients. Robotic-assisted gait training (RAGT) is an innovative method for its improvement. This study evaluates the influence of RAGT vs. dynamic parapodium training (DPT) in improving gait motor functions in SCI patients. In this single-centre, single-blinded study, we enrolled 105 (39 and 64 with complete and incomplete SCI, respectively) patients. The investigated subjects received gait training with RAGT (experimental S1-group) and DPT (control S0-group), with six training sessions per week over seven weeks. The American Spinal Cord Injury Association Impairment Scale Motor Score (MS), Spinal Cord Independence Measure, version-III (SCIM-III), Walking Index for Spinal Cord Injury, version-II (WISCI-II), and Barthel Index (BI) were assessed in each patient before and after sessions. Patients with incomplete SCI assigned to the S1 rehabilitation group achieved more significant improvement in MS [2.58 (SE 1.21, p < 0.05)] and WISCI-II [3.07 (SE 1.02, p < 0.01])] scores in comparison with patients assigned to the S0 group. Despite the described improvement in the MS motor score, no progression between grades of AIS (A to B to C to D) was observed. A nonsignificant improvement between the groups for SCIM-III and BI was found. RAGT significantly improved gait functional parameters in SCI patients in comparison with conventional gait training with DPT. RAGT is a valid treatment option in SCI patients in the subacute phase. DPT should not be recommended for patients with incomplete SCI (AIS-C); in those patients, RAGT rehabilitation programs should be taken into consideration.

A Multiaxial Rehabilitation Programme for Workers with COVID-19 Sequelae Using a Conventional and Technological-Robotic Approach: The Proposal of INAIL and Fondazione Don Carlo Gnocchi

The COVID-19 sequelae have been shown to affect respiratory and cardiological functions as well as neuro-psychological functions, and, in some cases, metabolic/nutritional aspects. The Italian National Institute for Insurance against Accidents at Work (Istituto Nazionale Assicurazione Infortuni sul Lavoro, INAIL) recorded that, until December 2022, 315,055 workers were affected by COVID-19; therefore, there is a need to identify an effective approach to treat such patients. Robotic and technological devices could be integrated into the rehabilitation programme of people with long COVID conditions. A review of the literature showed that telerehabilitation may improve functional capacity, dyspnoea, performance, and quality of life in these patients, but no studies were found evaluating the effects of robot-mediated therapy or virtual reality systems. Considering the above, Fondazione Don Carlo Gnocchi and INAIL propose a multi-axial rehabilitation for workers with COVID-19 sequelae. To accomplish this goal, the two institutions merged the epidemiological information gathered by INAIL, the expertise in robotic and technological rehabilitation of Fondazione Don Carlo Gnocchi, and the literature review. Our proposal aims to facilitate a multi-axial rehabilitation approach customized to meet the unique needs of each individual, with a particular emphasis on utilizing advanced technologies to address the current and future challenges of patient care.

Lower extremity robotic exoskeleton devices for overground ambulation recovery in acquired brain injury-A review

Acquired brain injury (ABI) is a leading cause of ambulation deficits in the United States every year. ABI (stroke, traumatic brain injury and cerebral palsy) results in ambulation deficits with residual gait and balance deviations persisting even after 1 year. Current research is focused on evaluating the effect of robotic exoskeleton devices (RD) for overground gait and balance training. In order to understand the device effectiveness on neuroplasticity, it is important to understand RD effectiveness in the context of both downstream (functional, biomechanical and physiological) and upstream (cortical) metrics. The review identifies gaps in research areas and suggests recommendations for future research. We carefully delineate between the preliminary studies and randomized clinical trials in the interpretation of existing evidence. We present a comprehensive review of the clinical and pre-clinical research that evaluated therapeutic effects of RDs using various domains, diagnosis and stage of recovery.

Therapeutic Effects of Robotic-Exoskeleton-Assisted Gait Rehabilitation and Predictive Factors of Significant Improvements in Stroke Patients: A Randomized Controlled Trial

Robotic-exoskeleton-assisted gait rehabilitation improves lower limb strength and functions in post-stroke patients. However, the predicting factors of significant improvement are unclear. We recruited 38 post-stroke hemiparetic patients whose stroke onsets were <6 months. They were randomly assigned to two groups: a control group receiving a regular rehabilitation program, and an experimental group receiving in addition a robotic exoskeletal rehabilitation component. After 4 weeks of training, both groups showed significant improvement in the strength and functions of their lower limbs, as well as health-related quality of life. However, the experimental group showed significantly better improvement in the following aspects: knee flexion torque at 60°/s, 6 min walk test distance, and the mental subdomain and the total score on a 12-item Short Form Survey (SF-12). Further logistic regression analyses showed that robotic training was the best predictor of a greater improvement in both the 6 min walk test and the total score on the SF-12. In conclusion, robotic-exoskeleton-assisted gait rehabilitation improved lower limb strength, motor performance, walking speed, and quality of life in these stroke patients.

Functional-oriented, portable brain-computer interface training for hand motor recovery after stroke: a randomized controlled study

Background

Brain-computer interfaces (BCIs) have been proven to be effective for hand motor recovery after stroke. Facing kinds of dysfunction of the paretic hand, the motor task of BCIs for hand rehabilitation is relatively single, and the operation of many BCI devices is complex for clinical use. Therefore, we proposed a functional-oriented, portable BCI equipment and explored the efficiency of hand motor recovery after a stroke.

Materials and methods

Stroke patients were randomly assigned to the BCI group and the control group. The BCI group received BCI-based grasp/open motor training, while the control group received task-oriented guidance training. Both groups received 20 sessions of motor training in 4 weeks, and each session lasted for 30 min. The Fugl-Meyer assessment of the upper limb (FMA-UE) was applied for the assessment of rehabilitation outcomes, and the EEG signals were obtained for processing.

Results

The progress of FMA-UE between the BCI group [10.50 (5.75, 16.50)] and the control group [5.00 (4.00, 8.00)] was significantly different (Z = -2.834, P = 0.005). Meanwhile, the FMA-UE of both groups improved significantly (P < 0.001). A total of 24 patients in the BCI group achieved the minimal clinically important difference (MCID) of FMA-UE with an effective rate of 80%, and 16 in the control group achieved the MCID, with an effective rate of 51.6%. The lateral index of the open task in the BCI group was significantly decreased (Z = -2.704, P = 0.007). The average BCI accuracy for 24 stroke patients in 20 sessions was 70.7%, which was improved by 5.0% in the final session compared with the first session.

Conclusion

Targeted hand movement and two motor task modes, namely grasp and open, to be applied in a BCI design may be suitable in stroke patients with hand dysfunction. The functional-oriented, portable BCI training can promote hand recovery after a stroke, and it is expected to be widely used in clinical practice. The lateral index change of inter-hemispheric balance may be the mechanism of motor recovery.

Trial registration number

ChiCTR2100044492.

Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications

Cerebral palsy (CP) is a congenital and permanent neurological disorder due to non-progressive brain damage that affects gross motor functions, such as balance, trunk control and gait. CP gross motor impairments yield more challenging right foot placement during gait phases, as well as the correct direction of the whole-body center of mass with a stability reduction and an increase in falling and tripping. For these reasons, robotic devices, thanks to their biomechanical features, can adapt easily to CP children, allowing better motor recovery and enjoyment. In fact, physiotherapists should consider each pathological gait feature to provide the patient with the best possible rehabilitation strategy and reduce extra energy efforts and the risk of falling in children affected by CP.

Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients

BACKGROUND

In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases.

METHODS

A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized.

RESULTS

The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables.

CONCLUSIONS

Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

Literature review of stroke assessment for upper-extremity physical function via EEG, EMG, kinematic, and kinetic measurements and their reliability

BACKGROUND

Significant clinician training is required to mitigate the subjective nature and achieve useful reliability between measurement occasions and therapists. Previous research supports that robotic instruments can improve quantitative biomechanical assessments of the upper limb, offering reliable and more sensitive measures. Furthermore, combining kinematic and kinetic measurements with electrophysiological measurements offers new insights to unlock targeted impairment-specific therapy. This review presents common methods for analyzing biomechanical and neuromuscular data by describing their validity and reporting their reliability measures.

METHODS

This paper reviews literature (2000-2021) on sensor-based measures and metrics for upper-limb biomechanical and electrophysiological (neurological) assessment, which have been shown to correlate with clinical test outcomes for motor assessment. The search terms targeted robotic and passive devices developed for movement therapy. Journal and conference papers on stroke assessment metrics were selected using PRISMA guidelines. Intra-class correlation values of some of the metrics are recorded, along with model, type of agreement, and confidence intervals, when reported.

RESULTS

A total of 60 articles are identified. The sensor-based metrics assess various aspects of movement performance, such as smoothness, spasticity, efficiency, planning, efficacy, accuracy, coordination, range of motion, and strength. Additional metrics assess abnormal activation patterns of cortical activity and interconnections between brain regions and muscle groups; aiming to characterize differences between the population who had a stroke and the healthy population.

CONCLUSION

Range of motion, mean speed, mean distance, normal path length, spectral arc length, number of peaks, and task time metrics have all demonstrated good to excellent reliability, as well as provide a finer resolution compared to discrete clinical assessment tests. EEG power features for multiple frequency bands of interest, specifically the bands relating to slow and fast frequencies comparing affected and non-affected hemispheres, demonstrate good to excellent reliability for populations at various stages of stroke recovery. Further investigation is needed to evaluate the metrics missing reliability information. In the few studies combining biomechanical measures with neuroelectric signals, the multi-domain approaches demonstrated agreement with clinical assessments and provide further information during the relearning phase. Combining the reliable sensor-based metrics in the clinical assessment process will provide a more objective approach, relying less on therapist expertise. This paper suggests future work on analyzing the reliability of metrics to prevent biasedness and selecting the appropriate analysis.

Lightweight Bioinspired Exoskeleton for Wrist Rehabilitation Powered by Twisted and Coiled Artificial Muscles

Stroke, cerebral palsy, and spinal cord injuries represent the most common leading causes of upper limb impairment. In recent years, rehabilitation robotics has progressed toward developing wearable technologies to promote the portability of assistive devices and to enable home rehabilitation of the upper extremities. However, current wearable technologies mainly rely on electric motors and rigid links or soft pneumatic actuators and are usually bulky and cumbersome. To overcome the limitations of existing technologies, in this paper, a first prototype of a lightweight, ungrounded, soft exoskeleton for wrist rehabilitation powered by soft and flexible carbon fibers-based twisted and coiled artificial muscles (TCAMs) is proposed. The device, which weighs only 0.135 kg, emulates the arrangement and working mechanism of skeletal muscles in the upper extremities and is able to perform wrist flexion/extension and ulnar/radial deviation. The range of motion and the force provided by the exoskeleton is designed through simple kinematic and dynamic theoretical models, while a thermal model is used to design a thermal insulation system for TCAMs during actuation. The device’s ability to perform passive and active-resisted wrist rehabilitation exercises and EMG-based actuation is also demonstrated.

Clinical efficacy of overground powered exoskeleton for gait training in patients with subacute stroke: A randomized controlled pilot trial

BACKGROUND

To investigate the efficacy and usefulness of 12 sessions of overground robot-assisted gait training (RAGT) in subacute stroke patients.

METHODS

In this pilot study, 17 subacute stroke survivors were randomly assigned to the intervention (n = 9) and control (n = 8) groups. In addition to the conventional stroke neurorehabilitation program, the intervention group received 30 minutes of overground exoskeletal RAGT, while the control group received 30 minutes of conventional gait training by a physiotherapist. All interventions were performed in 12 sessions (3 times/week for 4 weeks). The primary aim was to assess ambulation ability using the functional ambulation category (FAC). The 10-m walk test, Berg Balance Scale, timed-up-and-go Timed-up-and-go, Fugl-Meyer assessment of lower extremity, pulmonary function test, the Korean version of the modified Barthel index, and Euro quality of life-5 dimensions (EQ-5D) were assessed. All outcomes were evaluated both before and after the intervention.

RESULTS

The Berg Balance Scale, Korean version of the modified Barthel index, and EQ-5D scores (P < .05) improved significantly in both groups. Only those in the RAGT group improved significantly in the FAC, timed-up-and-go, and 10-m walk test (P < .05). In the FAC and EQ-5D, the intervention group showed greater improvement than the control group (P < .05).

CONCLUSION

We found that 4 weeks of overground RAGT combined with conventional training may improve walking independence and quality of life in patients with subacute stroke.

The Use of Sports Rehabilitation Robotics to Assist in the Recovery of Physical Abilities in Elderly Patients with Degenerative Diseases: A Literature Review

The increase in the number of elderly patients with degenerative diseases has brought additional medical and financial pressures, which are adding to the burden on society. The development of sports rehabilitation robotics (SRR) is becoming increasingly sophisticated at the technical level of its application; however, few studies have analyzed how it works and how effective it is in aiding rehabilitation, and fewer individualized exercise rehabilitation programs have been developed for elderly patients. The purpose of this study was to analyze the working methods and the effects of different types of SRR and then to suggest the feasibility of applying SRR to enhance the physical abilities of elderly patients with degenerative diseases. The researcher's team searched 633 English-language journal articles, which had been published over the past five years, and they selected 38 of them for a narrative literature review. Our summary found the following: (1) The current types of SRR are generally classified as end-effector robots, smart walkers, intelligent robotic rollators, and exoskeleton robots-exoskeleton robots were found to be the most widely used. (2) The current working methods include assistant tools as the main intermediaries-i.e., robots assist patients to participate; patients as the main intermediaries-i.e., patients dominate the assistant tools to participate; and sensors as the intermediaries-i.e., myoelectric-driven robots promote patient participation. (3) Better recovery was perceived for elderly patients when using SRR than is generally achieved through the traditional single-movement recovery methods, especially in strength, balance, endurance, and coordination. However, there was no significant improvement in their speed or agility after using SRR.

Lower limb exoskeleton robot and its cooperative control: A review, trends, and challenges for future research

Effective control of an exoskeleton robot (ER) using a human-robot interface is crucial for assessing the robot's movements and the force they produce to generate efficient control signals. Interestingly, certain surveys were done to show off cutting-edge exoskeleton robots. The review papers that were previously published have not thoroughly examined the control strategy, which is a crucial component of automating exoskeleton systems. As a result, this review focuses on examining the most recent developments and problems associated with exoskeleton control systems, particularly during the last few years (2017-2022). In addition, the trends and challenges of cooperative control, particularly multi-information fusion, are discussed.

Three-Dimensional Gait Analysis and sEMG Measures for Robotic-Assisted Gait Training in Subacute Stroke: A Randomized Controlled Trial

Background

The efficacy of robotic-assisted gait training (RAGT) should be considered versatilely; among which, gait assessment is one of the most important measures; observational gait assessment is the most commonly used method in clinical practice, but it has certain limitations due to the deviation of subjectivity; instrumental assessments such as three-dimensional gait analysis (3DGA) and surface electromyography (sEMG) can be used to obtain gait data and muscle activation during walking in stroke patients with hemiplegia, so as to better evaluate the rehabilitation effect of RAGT.

Objective

This single-blind randomized controlled trial is aimed at analyzing the impact of RAGT on the 3DGA parameters and muscle activation in patients with subacute stroke and evaluating the clinical effect of improving walking function of RAGT.

Methods

This randomized controlled trial evaluated the improvement of 4-week RAGT on patients with subacute stroke by 3DGA and surface electromyography (sEMG), combined with clinical scales: experimental group (n = 18, 20 sessions of RAGT) or control group (n = 16, 20 sessions of conventional gait training). Gait performance was evaluated by the 3DGA, and clinical evaluations based on Fugl-Meyer assessment for lower extremity (FMA-LE), functional ambulation category (FAC), and 6-minute walk test (6MWT) were used. Of these patients, 30 patients underwent sEMG measurement synchronized with 3DGA; the cocontraction index in swing phase of the knee and ankle of the affected side was calculated.

Results

After 4 weeks of intervention, intragroup comparison showed that walking speed, temporal symmetry, bilateral stride length, range of motion (ROM) of the bilateral hip, flexion angle of the affected knee, ROM of the affected ankle, FMA-LE, FAC, and 6MWT in the experimental group were significantly improved (p < 0.05), and in the control group, significant improvements were observed in walking speed, temporal symmetry, stride length of the affected side, ROM of the affected hip, FMA-LE, FAC, and 6MWT (p < 0.05). Intergroup comparison showed that the experimental group significantly outperformed the control group in walking speed, temporal symmetry of the spatiotemporal parameters, ROM of the affected hip and peak flexion of the knee in the kinematic parameters, and the FMA-LE and FAC in the clinical scale (p < 0.05). In patients evaluated by sEMG, the experimental group showed a noticeable improvement in the cocontraction index of the knee (p = 0.042), while no significant improvement was observed in the control group (p = 0.196), and the experimental group was better than the control group (p = 0.020). No noticeable changes were observed in the cocontraction index of the ankle in both groups (p > 0.05).

Conclusions

Compared with conventional gait training, RAGT successfully improved part of the spatiotemporal parameters of patients and optimized the motion of the affected lower limb joints and muscle activation patterns during walking, which is crucial for further rehabilitation of walking ability in patients with subacute stroke. This trial is registered with ChiCTR2200066402.

Biopsychosocial effects and experience of use of robotic and virtual reality devices in neuromotor rehabilitation: A study protocol

BACKGROUND

Robot-assisted therapy (RAT) and virtual reality (VR)-based neuromotor rehabilitation have shown promising evidence in terms of patient's neuromotor recovery, so far. However, still little is known on the perceived experience of use of robotic and VR devices and the related psychosocial impact. The present study outlines a study protocol aiming to investigate the biopsychosocial effects and the experience of use of robotic and non-immersive VR devices in patients undergoing neuromotor rehabilitation.

METHODS

Adopting a prospective, two-arm, non-randomized study design, patients with different neuromotor diseases (i.e., acquired brain injury, Parkinson's Disease, and total knee/hip arthroplasty) undergoing rehabilitation will be included. In a real-world clinical setting, short- (4 weeks) and long-term (6 months) changes in multiple patient's health domains will be investigated, including the functional status (i.e., motor functioning, ADLs, risk of falls), cognitive functioning (i.e., attention and executive functions), physical and mental health-related quality of life (HRQoL), and the psychological status (i.e., anxiety and depression, quality of life satisfaction). At post-intervention, the overall rehabilitation experience, the psychosocial impact of the robotic and VR devices will be assessed, and technology perceived usability and experience of use will be evaluated through a mixed-methods approach, including both patients' and physiotherapists' perspectives. Repeated measures within-between interaction effects will be estimated, and association analyses will be performed to explore the inter-relationships among the variables investigated. Data collection is currently ongoing.

IMPLICATIONS

The biopsychosocial framework adopted will contribute to expanding the perspective on patient's recovery within the technology-based rehabilitation field beyond motor improvement. Moreover, the investigation of devices experience of use and usability will provide further insight into technology deployment in neuromotor rehabilitation programs, thereby maximising therapy engagement and effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05399043.

Embodiment for Robotic Lower-Limb Exoskeletons: A Narrative Review

Research on embodiment of objects external to the human body has revealed important information about how the human nervous system interacts with robotic lower limb exoskeletons. Typical robotic exoskeleton control approaches view the controllers as an external agent intending to move in coordination with the human. However, principles of embodiment suggest that the exoskeleton controller should ideally coordinate with the human such that the nervous system can adequately model the input-output dynamics of the exoskeleton controller. Measuring embodiment of exoskeletons should be a necessary step in the exoskeleton development and prototyping process. Researchers need to establish high fidelity quantitative measures of embodiment, rather than relying on current qualitative survey measures. Mobile brain imaging techniques, such as high-density electroencephalography, is likely to provide a deeper understanding of embodiment during human-machine interactions and advance exoskeleton research and development. In this review we show why future exoskeleton research should include quantitative measures of embodiment as a metric of success.

Blending control method of lower limb exoskeleton toward tripping-free stair climbing

Tripping frequently occurs when an individual climbs the stairs with improper foot clearance. Among older adults, falling down the stairs accounts for over 10% of accidental deaths. This paper proposes an exoskeleton control method that blends human-dominant and exoskeleton-dominant control to prevent tripping. The blending controller not only allows the exoskeleton to track the pilot's movements and provide power assistance during regular walking, but also allows the exoskeleton to help the pilot avoid dangers in some cases. An online path planning method is used to generate a safe trajectory in the exoskeleton-dominant mode to help the pilot correct their running trajectory. The controller provides the pilot with adjustment spaces to adapt to sudden changes in the motion mode and enable active self-regulation. The simulations verified the effectiveness of the proposed blending method. Experiments showed that the robot should be involved in the pilot's movements when the foot clearance exceed the safety threshold to prevent tripping.

An impairment-specific hip exoskeleton assistance for gait training in subjects with acquired brain injury: a feasibility study

This study was designed to investigate the feasibility and the potential effects on walking performance of a short gait training with a novel impairment-specific hip assistance (iHA) through a bilateral active pelvis orthosis (APO) in patients with acquired brain injury (ABI). Fourteen subjects capable of independent gait and exhibiting mild-to-moderate gait deficits, due to an ABI, were enrolled. Subjects presenting deficit in hip flexion and/or extension were included and divided into two groups based on the presence (group A, n = 6) or absence (group B, n = 8) of knee hyperextension during stance phase of walking. Two iHA-based profiles were developed for the groups. The protocol included two overground gait training sessions using APO, and two evaluation sessions, pre and post training. Primary outcomes were pre vs. post-training walking distance and steady-state speed in the 6-min walking test. Secondary outcomes were self-selected speed, joint kinematics and kinetics, gait symmetry and forward propulsion, assessed through 3D gait analysis. Following the training, study participants significantly increased the walked distance and average steady-state speed in the 6-min walking tests, both when walking with and without the APO. The increased walked distance surpassed the minimal clinically important difference for groups A and B, (respectively, 42 and 57 m > 34 m). In group A, five out of six subjects had decreased knee hyperextension at the post-training session (on average the peak of the knee extension angle was reduced by 36%). Knee flexion during swing phase increased, by 16% and 31%, for A and B groups respectively. Two-day gait training with APO providing iHA was effective and safe in improving walking performance and knee kinematics in ABI survivors. These preliminary findings suggest that this strategy may be viable for subject-specific post-ABI gait rehabilitation.

Improving Upper Limb and Gait Rehabilitation Outcomes in Post-Stroke Patients: A Scoping Review on the Additional Effects of Non-Invasive Brain Stimulation When Combined with Robot-Aided Rehabilitation

Robot-aided rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are the two main interventions for post-stroke rehabilitation. The efficacy of both approaches in combination has not been well established yet. The importance of coupling these interventions, which both enhance brain plasticity to promote recovery, lies in augmenting the rehabilitation potential to constrain the limitation in daily living activities and the quality of life following stroke. This review aimed to evaluate the evidence of NIBS coupled with RAR in improving rehabilitation outcomes of upper limb and gait motor impairment in adult individuals with stroke. We included 18 clinical trials in this review. All studies were highly heterogeneous concerning the technical characteristics of robotic devices and NIBS protocols. However, the studies reported a global improvement in body structure and function and activity limitation for the upper limb, which were non-significant between the active and control groups. Concerning gait training protocols, the active group outperformed the control group in improving walking capacity and recovery. According to this review, NIBS and RAR in combination are promising but not yet largely recommendable as a systematic approach for stroke rehabilitation as there is not enough data about this. Therefore, more homogenous clinical trials are required, pointing out the best characteristics of the combined therapeutic protocols.

Assessment methodology for human-exoskeleton interactions: Kinetic analysis based on muscle activation

During the development and assessment of an exoskeleton, many different analyzes need to be performed. The most frequently used evaluate the changes in muscle activations, metabolic consumption, kinematics, and kinetics. Since human-exoskeleton interactions are based on the exchange of forces and torques, the latter of these, kinetic analyzes, are essential and provide indispensable evaluation indices. Kinetic analyzes, however, require access to, and use of, complex experimental apparatus, involving many instruments and implicating lengthy data analysis processes. The proposed methodology in this paper, which is based on data collected via EMG and motion capture systems, considerably reduces this burden by calculating kinetic parameters, such as torque and power, without needing ground reaction force measurements. This considerably reduces the number of instruments used, allows the calculation of kinetic parameters even when the use of force sensors is problematic, does not need any dedicated software, and will be shown to have high statistical validity. The method, in fact, combines data found in the literature with those collected in the laboratory, allowing the analysis to be carried out over a much greater number of cycles than would normally be collected with force plates, thus enabling easy access to statistical analysis. This new approach evaluates the kinetic effects of the exoskeleton with respect to changes induced in the user's kinematics and muscular activation patterns and provides indices that quantify the assistance in terms of torque (AMI) and power (API). Following the User-Center Design approach, which requires driving the development process as feedback from the assessment process, this aspect is critical. Therefore, by enabling easy access to the assessment process, the development of exoskeletons could be positively affected.

sEMG-Based Gain-Tuned Compliance Control for the Lower Limb Rehabilitation Robot during Passive Training

The lower limb rehabilitation robot is a typical man-machine coupling system. Aiming at the problems of insufficient physiological information and unsatisfactory safety performance in the compliance control strategy for the lower limb rehabilitation robot during passive training, this study developed a surface electromyography-based gain-tuned compliance control (EGCC) strategy for the lower limb rehabilitation robot. First, the mapping function relationship between the normalized surface electromyography (sEMG) signal and the gain parameter was established and an overall EGCC strategy proposed. Next, the EGCC strategy without sEMG information was simulated and analyzed. The effects of the impedance control parameters on the position correction amount were studied, and the change rules of the robot end trajectory, man-machine contact force, and position correction amount analyzed in different training modes. Then, the sEMG signal acquisition and feature analysis of target muscle groups under different training modes were carried out. Finally, based on the lower limb rehabilitation robot control system, the influence of normalized sEMG threshold on the robot end trajectory and gain parameters under different training modes was experimentally studied. The simulation and experimental results show that the adoption of the EGCC strategy can significantly enhance the compliance of the robot end-effector by detecting the sEMG signal and improve the safety of the robot in different training modes, indicating the EGCC strategy has good application prospects in the rehabilitation robot field.

Parallel assistive robotic system for knee rehabilitation: kinematic and dynamic modeling validation

The knee joint is frequently exposed to injuries in people of all ages. In some cases, physical therapy is prescribed to recover the strength and mobility of a patient. The robotic assistance devices are gaining community attention and aim to improve the quality of life of people. In this work, we present the kinematic and dynamic modelling of a five-bar-linkage assistive device for knee rehabilitation according to anthropometric data from Latin-American population. We obtain a dynamic model of the proposed rehabilitation system and compare the knee trajectories with obtained using the assistive system to evaluate appropriate control strategies in the future. For this purpose, we present the kinematic formulation of the device, and then we derive the dynamics using two approaches to validate the model; we obtain the motion equation using the Lagrange approach and an algebraic method that simplifies modelling. Both approaches yield a unique model, which is validated either in simulation and by experimental trials, showing the functionality of the system and the validity of the models when performing rehabilitation routines.

Development of inductive sensors for a robotic interface based on noninvasive tongue control

Tongue based robotic interfaces have shown the potential to control assistive robotic devices developed for individuals with severe disabilities due to spinal cord injury. However, current tongue-robotic interfaces require invasive methods such as piercing to attach an activation unit (AU) to the tongue. A noninvasive tongue interface concept, which used a frame integrated AU instead of a tongue attached AU, was previously proposed. However, there is a need for the development of compact one-piece sensor printed circuit boards (PCBs) to enable activation of all inductive sensors. In this study, we developed and tested four designs of compact one-piece sensor PCBs incorporating inductive sensors for the design of a noninvasive tongue-robotic interface. We measured electrical parameters of the developed sensors to detect activation and compared them with a sensor of the current version of the inductive tongue-computer interface (ITCI) by moving AUs with different contact surfaces at the surface of the sensors. Results showed that, the newly developed inductive sensors had higher and wider activation than the sensor of ITCI and the AU with a flat contact surface had 3.5 - 4 times higher activation than the AU with a spherical contact surface. A higher sensor activation can result in a higher signal to noise ratio and thus a higher AU tracking resolution.

Preliminary Validation of Proportional Myoelectric Control of A Commercially Available Robotic Ankle Exoskeleton

Proportional myoelectric control of robotic lower limb exoskeletons can increase the variability and adaptability of biomechanical behaviors for assisting human movement compared to traditional state-based control. Previous exoskeletons using proportional myoelectric control have relied on pneumatic actuators and been limited to laboratory use. We applied proportional myoelectric control to a robotic ankle exoskeleton using a brushless DC motor (Dephy) and enabled it to work in community settings. Benchtop testing verified electromechanical responses similar to biological values (electromechanical delay of 22 ms and time to peak activation of 123 ms). Four healthy participants trained for thirty minutes each using bilateral ankle exoskeletons. From minute one of powered walking to minute 30 of powered walking, peak soleus EMG reduced by 17.9% as they learned to walk with exoskeleton assistance. Our future work will extend the powered walking period, measure metabolic cost, and measure gait variability between participants using proportional myoelectric control on fully portable, electromechanical ankle exoskeletons.

Evaluation of the implementation of Armeo®Spring in a specialized neurorehabilitation center

Rehabilitation of the upper extremity (UE) is an essential part of the process following an acquired brain injury, where robot technologies have the potential of making the rehabilitation more intensive and effective. However, the implementation of robot technologies in a clinical setting can be complicated and not always successful. The aim of this study was to evaluate the implementation of the robot technology Armeo®Spring (Hocoma, Volketswil, Switzerland) at a specialized neurorehabilitation center, and to propose a list of actions for further implementation of the technology.The Study, Act and Plan phases of the Plan-Do-Study-Act (PDSA) model for structuring technology implementations was applied as the methodological framework in this study. In the Study-phase, nine semi-structured interviews with therapists, using Armeo®Spring, were conducted to evaluate the current implementation. In the Act-phase, a workshop was held with 13 participants to discuss the findings of the Study-phase and to find possible solutions to the identified problems. The results were incorporated into a list of actions (Plan-phase) for further implementation of Armeo®Spring.Facilitating and inhibiting factors for the implementation of Armeo®Spring were identified. Facilitating factors were the practical "hands-on" approach during training, support from the management, support and sparring with colleagues as well as a positive work culture. The inhibiting factors were related to the retention of the therapists' acquired competencies, the identification of the type of patient that can benefit from this form of training, challenges due to the technical use of Armeo®Spring, and prioritization of the rehabilitation needs of the patients.Several solutions were proposed in the Act-phase, which subsequently resulted in eight concrete actions to facilitate the further implementation of Armeo®Spring. It is expected that these actions will contribute to the further implementation of Armeo®Spring at the neurorehabilitation center. As a first step, an Armeo®Spring group with therapists from all relevant wards was established.

Hand Rehabilitation Devices: A Comprehensive Systematic Review

A cerebrovascular accident, or a stroke, can cause significant neurological damage, inflicting the patient with loss of motor function in their hands. Standard rehabilitation therapy for the hand increases demands on clinics, creating an avenue for powered hand rehabilitation devices. Hand rehabilitation devices (HRDs) are devices designed to provide the hand with passive, active, and active-assisted rehabilitation therapy; however, HRDs do not have any standards in terms of development or design. Although the categorization of an injury’s severity can guide a patient into seeking proper assistance, rehabilitation devices do not have a set standard to provide a solution from the beginning to the end stages of recovery. In this paper, HRDs are defined and compared by their mechanical designs, actuation mechanisms, control systems, and therapeutic strategies. Furthermore, devices with conducted clinical trials are used to determine the future development of HRDs. After evaluating the abilities of 35 devices, it is inferred that standard characteristics for HRDs should include an exoskeleton design, the incorporation of challenge-based and coaching therapeutic strategies, and the implementation of surface electromyogram signals (sEMG) based control.

Robot Assisted Gait Training in a Patient with Ataxia

Background: Ataxia is a neurological sign characterized by motor coordination during gait/voluntary limb movements impairment. Ataxic gait leads to disability and worsening of quality of life; physiotherapy intervention is recommended to improve motor function. Recent studies showed benefits due to repetitive robotized assisted gait training using a static exoskeleton in patients affected by acquired ataxias. The aim of the study was to perform a preliminary evaluation of the short-term effects of overground UAN.GO^®-assisted gait training in an adult patient with ataxia but with no clear genetic pattern. Methods: This case report study was conducted on a single male adult patient, who presented ataxic spastic gait, posterior chain tightness, pes cavus, and unstable standing position. The patient underwent two preliminary sessions to take part in the study. Treatment protocol planned 10 sessions and each one lasted 80 min, 60 of which were spent in gait training using the mobile overground exoskeleton UAN.GO^®. At T1 (start of the study) and T10 (final evaluation) assessments using the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, 6-Minute Walking Test, and Likert Scale were administered. Space-time parameters of gait cycle were also evaluated: left and right step length, stance and swing percentages. Results: improvements on the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, and in the distance travelled at 6-Minute Walking Test emerged. The patient gave a positive opinion towards the treatment, showed by Likert Scale results. Kinematic gait analysis showed more physiological step length, stance and swing percentages, joint angles. The patient completed the training program with an excellent compliance. Discussion: Since these encouraging outcomes were obtained, it is possible to consider robot-assisted gait training performed with UAN.GO^® as a therapeutic option to improve motor and functional performance in patients with ataxic gait.

Efficacy of Overground Robotic Gait Training on Balance in Stroke Survivors: A Systematic Review and Meta-Analysis

Strokes often lead to a deficit in motor control that contributes to a reduced balance function. Impairments in the balance function severely limit the activities of daily living (ADL) in stroke survivors. The present systematic review and meta-analysis primarily aims to explore the efficacy of overground robot-assisted gait training (o-RAGT) on balance recovery in individuals with stroke. In addition, the efficacy on ADL is also investigated. This systematic review identified nine articles investigating the effects of o-RAGT on balance, four of which also assessed ADL. The results of the meta-analysis suggest that o-RAGT does not increase balance and ADL outcomes more than conventional therapy in individuals after stroke. The data should not be overestimated due to the low number of studies included in the meta-analysis and the wide confidence intervals. Subgroup analyses to investigate the influence of participant’s characteristics and training dosage were not performed due to lack of data availability. Further well-designed randomized controlled trials are needed to investigate the efficacy of o-RAGT on balance in individuals with stroke.

A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective

BACKGROUND

The application of virtual reality (VR) and robotic devices in neuromotor rehabilitation has provided promising evidence in terms of efficacy, so far. Usability evaluations of these technologies have been conducted extensively, but no overviews on this topic have been reported yet.

METHODS

A systematic review of the studies on patients' and healthcare professionals' perspective through searching of PubMed, Medline, Scopus, Web of Science, CINAHL, and PsychINFO (2000 to 2021) was conducted. Descriptive data regarding the study design, participants, technological devices, interventions, and quantitative and qualitative usability evaluations were extracted and meta-synthetized.

RESULTS

Sixty-eight studies were included. VR devices were perceived as having good usability and as a tool promoting patients' engagement and motivation during the treatment, as well as providing strong potential for customized rehabilitation sessions. By contrast, they suffered from the effect of learnability and were judged as potentially requiring more mental effort. Robotics implementation received positive feedback along with high satisfaction and perceived safety throughout the treatment. Robot-assisted rehabilitation was considered useful as it supported increased treatment intensity and contributed to improved patients' physical independence and psychosocial well-being. Technical and design-related issues may limit the applicability making the treatment difficult and physically straining. Moreover, cognitive and communication deficits were remarked as potential barriers.

CONCLUSIONS

Overall, VR and robotic devices have been perceived usable so far, reflecting good acceptance in neuromotor rehabilitation programs. The limitations raised by the participants should be considered to further improve devices applicability and maximise technological rehabilitation effectiveness.

TRIAL REGISTRATION

PROSPERO registration ref. CRD42021224141 .

Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review

Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.

Whole-Body Adaptive Functional Electrical Stimulation Kinesitherapy Can Promote the Restoring of Physiological Muscle Synergies for Neurological Patients

Background: Neurological diseases and traumas are major factors that may reduce motor functionality. Functional electrical stimulation is a technique that helps regain motor function, assisting patients in daily life activities and in rehabilitation practices. In this study, we evaluated the efficacy of a treatment based on whole-body Adaptive Functional Electrical Stimulation Kinesitherapy (AFESK™) with the use of muscle synergies, a well-established method for evaluation of motor coordination. The evaluation is performed on retrospectively gathered data of neurological patients executing whole-body movements before and after AFESK-based treatments. Methods: Twenty-four chronic neurologic patients and 9 healthy subjects were recruited in this study. The patient group was further subdivided in 3 subgroups: hemiplegic, tetraplegic and paraplegic. All patients underwent two acquisition sessions: before treatment and after a FES based rehabilitation treatment at the VIKTOR Physio Lab. Patients followed whole-body exercise protocols tailored to their needs. The control group of healthy subjects performed all movements in a single session and provided reference data for evaluating patients’ performance. sEMG was recorded on relevant muscles and muscle synergies were extracted for each patient’s EMG data and then compared to the ones extracted from the healthy volunteers. To evaluate the effect of the treatment, the motricity index was measured and patients’ extracted synergies were compared to the control group before and after treatment. Results: After the treatment, patients’ motricity index increased for many of the screened body segments. Muscle synergies were more similar to those of healthy people. Globally, the normalized synergy similarity in respect to the control group was 0.50 before the treatment and 0.60 after (p < 0.001), with improvements for each subgroup of patients. Conclusions: AFESK treatment induced favorable changes in muscle activation patterns in chronic neurologic patients, partially restoring muscular patterns similar to healthy people. The evaluation of the synergic relationships of muscle activity when performing test exercises allows to assess the results of rehabilitation measures in patients with impaired locomotor functions.

Efficacy of robotic exoskeleton for gait rehabilitation in patients with subacute stroke : a systematic review

BACKGROUND

Stroke is the most common cause of disability in Western Countries. It can lead to loss of mobility, capability to walk and ultimately loss of independence in activities of daily living (ADL). Several rehabilitative approaches have been proposed in these years. Robot-assisted gait rehabilitation (RAGT) plays a crucial role to perform a repetitive, intensive, and task-oriented treatment in stroke survivors. However, there are still few data on its role in subacute stroke patients.

AIM

The aim of the present study was to assess the efficacy of RAGT for gait recovery in subacute stroke survivors.

DESIGN

Systematic review with meta-analysis.

SETTING

The setting of the study included Units of Rehabilitation.

POPULATION

The analyzed population was represented by subacute stroke patients.

METHODS

PubMed, Scopus, Web of Science, CENTRAL, and PEDro were systematically searched until January 18, 2021, to identify randomized controlled trials (RCTs) presenting: stroke survivors in subacute phase (≤6 months) as participants; exoskeleton robots devices as intervention; conventional rehabilitation as a comparator; gait assessment, through qualitative scales, quantitative gait scales or quantitative parameters, as outcome measures. We also performed a meta-analysis of the mean difference in the functional ambulation category (FAC) via the random effect method.

RESULTS

Out of 3188 records, 14 RCTs were analyzed in this systematic review. The 14 studies have been published in the last 14 years (from 2006 to 2021) and included 576 stroke survivors, of which 306 received RAGT, and 270 underwent conventional rehabilitation. Lokomat robotic system was the most investigated robotic exoskeleton by the RCTs included (N.=9), albeit the meta-analysis demonstrated a non-significant difference of -0.09 in FAC (95% CI: -0.22.0.03) between Lokomat and conventional therapy. According to the PEDro scale, 11 (78.5%) were classified as good-quality studies, two as fair-quality studies (14.3%), and one as poor-quality study (7.1%).

CONCLUSIONS

Taken together, these findings showed that RAGT might have a potential role in gait recovery in subacute stroke survivors. However, further RCTs comparing the efficacy of RAGT with conventional physical therapy are still warranted in the neurorehabilitation field.

CLINICAL REHABILITATION IMPACT

This systematic review provides information on the efficacy of RAGT in allowing subacute stroke patients to perform high-intensity gait training with a lower physical burden on PRM professionals.

Variable Admittance Control of a Hand Exoskeleton for Virtual Reality-Based Rehabilitation Tasks

Robot-based rehabilitation is consolidated as a viable and efficient practice to speed up and improve the recovery of lost functions. Several studies highlight that patients are encouraged to undergo their therapies and feel more involved in the process when collaborating with a user-friendly robotic environment. Object manipulation is a crucial element of hand rehabilitation treatments; however, as a standalone process may result in being repetitive and unstimulating in the long run. In this view, robotic devices, like hand exoskeletons, do arise as an excellent tool to boost both therapy's outcome and patient participation, especially when paired with the advantages offered by interacting with virtual reality (VR). Indeed, virtual environments can simulate real-life manipulation tasks and real-time assign a score to the patient's performance, thus providing challenging exercises while promoting training with a reward-based system. Besides, they can be easily reconfigured to match the patient's needs by manipulating exercise intensity, e.g., Assistance-As-Needed (AAN) and the required tasks. Modern VR can also render interaction forces when paired to wearable devices to give the user some sort of proprioceptive force or tactile feedback. Motivated by these considerations, a Hand Exoskeleton System (HES) has been designed to be interfaced with a variable admittance control to achieve VR-based rehabilitation tasks. The exoskeleton assists the patient's movements according to force feedback and following a reference value calculated inside the VR. Whenever the patient grasps a virtual object, the HES provides the user with a force feedback sensation. In this paper, the virtual environment, developed within the Webots framework and rendering a HES digital-twin mapping and mimicking the actual HES motion, will be described in detail. Furthermore, the admittance control strategy, which continuously varies the control parameters to best render the force sensation and adapt to the user's motion intentions, will be investigated. The proposed approach has been tested on a single subject in the framework of a pilot study.

Effect of Reciprocating Gait Orthosis with Hip Actuation on Upper Extremity Loading during Ambulation in Patient with Spinal Cord Injury: A Single Case Study

Reciprocating gait orthosis (RGO) is a traditional passive orthosis that provides postural stability and allows for independent upright ambulation with the assistance of walking aids, such as crutches, canes, and walkers. Previous follow-up studies of patients with RGOs have indicated a high frequency of nonusage. One of the main reasons for avoiding the use of RGOs is the excessive upper extremity loading induced by walking aids. The purpose of this study was to investigate the effect of hip actuation on the upper extremity loading induced by crutches when ambulating with an RGO. One female individual with a chronic complete spinal cord injury classified as ASIA A participated in this study. We compared the upper extremity loading during ambulation when individualized hip assistive forces were applied on the RGO (POWERED condition) and when wearing the RGO without actuation (RGO condition). Upper extremity loading was assessed by measuring the forces acting on the crutches. Compared with the RGO condition, the average upper extremity loading per unit distance and per unit time were lower for the POWERED condition by 15.21% (RGO: 0.307 ± 0.056 and POWERED: 0.260 ± 0.034 %bw·m−1) and by 21.19% (RGO: 0.120 ± 0.020 and POWERED: 0.094 ± 0.011 %bw·s−1), respectively. We believe that a substantial reduction in upper extremity loading during ambulation provided by hip actuation holds promise to promote long-term RGO use and enable patients with paraplegia to perform frequent and intensive rehabilitation training. As this is a single case study, subsequent studies should aim to verify this effect through a higher number of patients and to different injury levels.

Information Security in Medical Robotics: A Survey on the Level of Training, Awareness and Use of the Physiotherapist

Cybersecurity is becoming an increasingly important aspect to investigate for the adoption and use of care robots, in term of both patients' safety, and the availability, integrity and privacy of their data. This study focuses on opinions about cybersecurity relevance and related skills for physiotherapists involved in rehabilitation and assistance thanks to the aid of robotics. The goal was to investigate the awareness among insiders about some facets of cybersecurity concerning human-robot interactions. We designed an electronic questionnaire and submitted it to a relevant sample of physiotherapists. The questionnaire allowed us to collect data related to: (i) use of robots and its relationship with cybersecurity in the context of physiotherapy; (ii) training in cybersecurity and robotics for the insiders; (iii) insiders' self-assessment on cybersecurity and robotics in some usage scenarios, and (iv) their experiences of cyber-attacks in this area and proposals for improvement. Besides contributing some specific statistics, the study highlights the importance of both acculturation processes in this field and monitoring initiatives based on surveys. The study exposes direct suggestions for continuation of these types of investigations in the context of scientific societies operating in the rehabilitation and assistance robotics. The study also shows the need to stimulate similar initiatives in other sectors of medical robotics (robotic surgery, care and socially assistive robots, rehabilitation systems, training for health and care workers) involving insiders.

Efficiency of Leg Exoskeleton Use in Rehabilitation of Cerebral Stroke Patients

The study aimed to evaluate the effectiveness of functional and motor activity restoration, including the walking function, in patients after an ischemic stroke using the ExoAtlet lower limb exoskeleton.

Patients and methods. A clinical study was carried out on 42 patients who had undergone a cerebral infarction in the mid cerebral artery system with a post-stroke paresis of the leg, and who had undergone a rehabilitation course in a round-theclock hospital during the early recovery period. Patients were randomized into two equal groups comparable in terms of the stroke severity: the patients in group 1 were receiving a standard rehabilitation program (control group), the patients in group 2 were additionally receiving a course of gait rehabilitation using the ExoAtlet exoskeleton - 10 sessions, 5 sessions per week for 14 days.

Results. The study demonstrated the effectiveness of the ExoAtlet exoskeleton used in the rehabilitation of stroke patients over the standard course of rehabilitation. The advantages include a decrease in the hemiparesis degree, an increase in the muscle strength of the paretic limb, an improvement in balance, an improvement and acceleration of the walking process. The obtained results of the instrumental study confirmed the benefits of physical training on the Exoskeleton, which was demonstrated through an increase in stability and balance, as well as through a decrease in the energy consumption index for maintaining the stable verticalization.

Conclusion. The usage of the ExoAtlet exoskeleton increases the effectiveness of rehabilitation measures and improves motor and functional activities of patients who have suffered a cerebral stroke.

Characteristics and Applications of Technology-Aided Hand Functional Assessment: A Systematic Review

Technology-aided hand functional assessment has received considerable attention in recent years. Its applications are required to obtain objective, reliable, and sensitive methods for clinical decision making. This systematic review aims to investigate and discuss characteristics of technology-aided hand functional assessment and their applications, in terms of the adopted sensing technology, evaluation methods and purposes. Based on the shortcomings of current applications, and opportunities offered by emerging systems, this review aims to support the design and the translation to clinical practice of technology-aided hand functional assessment. To this end, a systematic literature search was led, according to recommended PRISMA guidelines, in PubMed and IEEE Xplore databases. The search yielded 208 records, resulting into 23 articles included in the study. Glove-based systems, instrumented objects and body-networked sensor systems appeared from the search, together with vision-based motion capture systems, end-effector, and exoskeleton systems. Inertial measurement unit (IMU) and force sensing resistor (FSR) resulted the sensing technologies most used for kinematic and kinetic analysis. A lack of standardization in system metrics and assessment methods emerged. Future studies that pertinently discuss the pathophysiological content and clinimetrics properties of new systems are required for leading technologies to clinical acceptance.